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Chest Pain in Children

Michael A. Davis, MD

Chest pain is the presenting complaint in 6 per 1,000 children who present to pediatric emergency departments or walk-in clinics. Young children are more likely to have a cardiorespiratory cause of their pain, such as cough, asthma, pneumonia, or heart disease; adolescents are more likely to have pain associated with a psychogenic disturbance.

Differential Diagnosis of Chest Pain in Children

Cardiac Disease

Cardiac disease is a rare cause of chest pain in children. However, myocardial infarction can rarely result from anomalous coronary arteries, and there may be no warning of this condition. Some children will have a pansystolic, continuous, or mitral regurgitation murmur or gallop rhythm that suggests myocardial dysfunction.

Arrhythmias may cause palpitations or abnormalities on cardiac examination in some children. Supraventricular tachycardia is the most common arrhythmia, but premature ventricular beats or tachycardia also can cause episodes of brief, sharp chest pain.

Hypertrophic obstructive cardiomyopathy is an autosomal dominant structural disorder; therefore, there often is a family history of the condition. Children may have a murmur that may be audible when standing or when performing a Valsalva maneuver. These patients are at risk for ischemic chest pain.

Mitral valve prolapse may cause chest pain secondary to papillary muscle or endocardial ischemia. A midsystolic click and a late systolic murmur may be detected.

Cardiac infections are uncommon causes of pediatric chest pain.

Pericarditis presents with sharp, stabbing pain that improves when the patient sits up and leans forward. The child usually is febrile; is in respiratory distress; and has a friction rub, distant heart sounds, neck vein distention, and pulsus paradoxus.

Myocarditis presents as mild pain that has been present for several days. After a few days of fever, vomiting and lightheadedness, the patient may develop pain or shortness of breath on exertion. Examination may reveal muffled heart sounds, fever, a gallop rhythm, or tachycardia. The patient also may have orthostatic changes in pulse or blood pressure (pulse increase >30 beats/min, blood pressure decrease >20 mm Hg when moving from supine to standing).

Chest radiography will show cardiomegaly in both of these infections, and the electrocardiogram will be abnormal. An echocardiogram will confirm the diagnosis.

Musculoskeletal Pain

This is one of the most common diagnoses in children who have chest discomfort. Children frequently strain chest wall muscles while exercising.

Trauma to the chest may result in a mild contusion or a rib fracture. The physical examination will reveal chest tenderness.

Costochondritis is common in children, and it is characterized by tenderness over the costochondral junctions with palpation. The pain is sharp and exaggerated by physical activity or breathing.

Respiratory Conditions

Severe cough, asthma, or pneumonia may cause chest pain because of overuse of chest wall muscles. Crackles, wheezes, tachypnea, or decreased breath sounds are present.

Exercise-induced asthma may cause chest pain, which can be confirmed with a treadmill test.

Spontaneous pneumothorax or pneumomediastinum may occasionally cause chest pain with respiratory distress. Children with asthma, cystic fibrosis, or Marfan syndrome are at high risk for these conditions, but previously healthy children may rupture an unrecognized subpleural bleb. Signs include respiratory distress, decreased breath sounds on the affected side, and palpable subcutaneous air.

Pulmonary embolism is extremely rare in pediatric patients, but it should be considered in the adolescent girl who has dyspnea, fever, pleuritic pain, cough, and hemoptysis. Oral contraceptives or recent abortion increase the risk. Young males who have had recent leg trauma also are at risk.

Psychogenic disturbances can precipitate chest pain. These children may present with hyperventilation or an anxious appearance. A recent stressful event (separation from friends, parental divorce, school failure) may often be related temporally to the onset of the chest pain.

Gastrointestinal Disorders

Reflux esophagitis often causes chest pain which is described as burning, substernal, and worsened by reclining or eating spicy foods. This condition is confirmed with a therapeutic trial of antacids.

Foreign body ingestion may cause chest pain when the object lodges in the esophagus. A radiograph confirms the diagnosis.

Miscellaneous Causes of Pediatric Chest Pain

Sickle cell disease may cause an acute chest syndrome.

Marfan syndrome may cause chest pain and fatal abdominal aortic aneurysm dissection.

Collagen vascular disorders may cause chest pain and pleural effusions.

Shingles may cause chest pain that precedes or occurs simultaneously with the rash.

Coxsackievirus infection may lead to pleurodynia with paroxysms of sharp chest pain.

Breast tenderness during puberty or early breast changes of pregnancy may present as chest pain.

Idiopathic Chest Pain. No diagnosis can be determined in 20-45% of cases of pediatric chest pain.

Clinical Evaluation of Chest Pain

A history and physical examination will reveal the etiology of chest pain in most cases. The history may reveal asthma, previous heart disease, or Kawasaki disease. Family history may reveal familial hypertrophic obstructive cardiomyopathy.

The frequency and severity of the pain and whether the pain interrupts the child's daily activity should be determined. Pain that wakes the child from sleep is more likely to be related to an organic etiology.

Burning pain in the sternal area suggests esophagitis. Sharp stabbing pain that is relieved by sitting up and leaning forward suggests pericarditis in a febrile child.

Mode of Onset of Pain. Acute onset of pain is more likely to represent an organic etiology. Chronic pain is much more likely to have a idiopathic or psychogenic origin.

Precipitating Factors

Trauma, muscle strain, or choking on a foreign body should be sought.

Exercise induced chest pain should be taken seriously because it may be caused by cardiac disease or exercise-induced asthma.

Syncope, fever or palpitations associated with chest pain should be carefully assessed.

Joint pain, rash, or fever may be suggested by the presence of collagen vascular disease.

Stressful conditions at home or school should be sought.

Substance abuse (cocaine) or oral contraceptives should be sought in adolescents.

Physical Examination

Severe distress warrants immediate treatment for life-threatening conditions, such as pneumothorax.

Hyperventilation may be distinguished from respiratory distress by the absence of cyanosis or nasal flaring.

Pallor, poor growth may suggest that the chest pain is caused by a malignancy or collagen vascular disease.

Abdominal tenderness should be sought because it may be a source of pain that is referred to the chest.

Rales, wheezes, decreased breath sounds, murmurs, rubs, muffled heart sounds, or arrhythmias suggests cardiopulmonary pathology.

The chest wall should be evaluated for bruises (trauma), tenderness (musculoskeletal pain), or subcutaneous air (pneumothorax or pneumomediastinum).

Laboratory Evaluation

A chest radiograph is warranted if the patient has fever, respiratory distress, or abnormal breath sounds. Fever and cardiomegaly suggests pericarditis or myocarditis.

Electrocardiography is recommended if the pain was acute in onset (began in the last 2-3 days) or if there is an abnormal cardiac examination (unexplained tachycardia, arrhythmia, murmur, rub, or click).

Exercise stress testing or pulmonary function testing is appropriate for evaluation of cardiac disease or asthma.

Holter monitoring and evaluation for an arrhythmia or structural heart disease is warranted for syncope or palpitations.

Children with chronic pain, a normal physical examination, and no history suggestive of cardiac or pulmonary disease do not require laboratory studies.

Blood counts and sedimentation rates are of limited value unless collagen vascular disease, infection, or malignancy is suspected.

Drug screening may be indicated in the older child who has acute pain associated with anxiety, tachycardia, hypertension, or shortness of breath.

Management of Pediatric Chest Pain

Emergency department referral is necessary if the child is in severe distress or has a history of significant trauma.

Referral to a cardiologist is recommended for children with known or suspected heart disease, syncope, palpitations, or pain on exertion.

Musculoskeletal, psychogenic, or idiopathic pain usually will respond to reassurance, analgesics, rest, and application of a heating pad. If esophagitis is suspected, a trial of antacids may be beneficial. §